TN 2 (08-16)

Citations:

Social Security Act Section 205(b);

20 CFR 404.907 - 404.922, 404.993, 404.999a - 404.999d, 404.1546, 404.1597, 404.1597a,416.946, 416.995, 416.996 , 416.1407 - 416.1422, 416.1492 - 416.1493, 416.1495 - 416.1499, and 422.140

A. Levels in the appeal process

Individuals have the right to appeal an unfavorable CDR determination.

This subchapter focuses on the reconsideration level only.

There are four levels of appeal:

1. Reconsideration. This includes:

   • Pre-hearing - review by an adjudicative team, or designated person, that was not involved in the initial unfavorable determination

   • Disability hearing - review within a disability hearing unit (DHU) by a disability hearing officer (DHO)

2. Hearing by an administrative law judge

3. Review by the Appeals Council

4. Federal Court review

B. The disability hearing at the reconsideration level

A disability hearing is a face-to-face evidentiary meeting that enables the individual to review the evidence, introduce new evidence, and present his or her objections to a medical determination before a DHO.

NOTE: The disability hearing at the reconsideration level applies only to CDR determinations, and does not apply to determinations based on an initial disability claim.

For information on initial disability claims, see DI 12005.001.

C. Basics of the reconsideration CDR

The Social Security Act affords an individual the right to a disability hearing at the reconsideration level of appeal in certain Title II and Title XVI cases.

1. Types of cases with appeal rights

Cases include an appeal of a medical determination that resulted in a(n):

• Medical cessation;

• Adverse medical reopening;

• Reopening that changes only the basis of the cessation; or

• Reopening that proposes an adverse revision.

The disability hearing process applies to the medical determinations noted here, including the medical issues involving:

• Medicare for qualified government employees (MQGE) cases;

• Extended period of eligibility (EPE) cases;

• Prisoner cases;

• Foreign cases;

• Railroad cases.

2. When a reconsideration CDR applies

Reconsideration applies when:

• An initial CDR determination finds, based on medical or medical-vocational factors, an individual's impairment ceased, did not exist, or is no longer disabling; or

• The Social Security Administration (SSA) proposes to adversely reopen and revise a favorable determination based on medical or medical-vocational factors. For more information on reopenings, see DI 33020.025.

3. When a reconsideration CDR does not apply

A disability hearing is NOT applicable for:

• Initial determinations made on a new application, (including closed period cases), unless it is forwarded for association with a prior case that is subject to the reconsideration CDR process.

• Reconsideration of initial determinations made on new applications, including partially favorable determinations (e.g., closed periods and later onsets).

• Cases involving non-medical issues, e.g., substantial gainful activity, overpayment of benefits, amount of income and resources (Title XVI), or reconsideration of cessations based on whereabouts unknown.

D. References

• DI 12005.001 Documenting a Request for Reconsideration of an Initial Disability Claim

• DI 29001.001 The Right to a Disability Hearing at the Medical Continuing Disability Review (CDR) Reconsideration Level

• DI 29001.005 The Scope of the Disability Hearing

• DI 29001.010 Overview of Component Responsibilities Related to Medical Continuing Disability (CDR) Disability Hearings

• DI 29005.022 New Application and Request for Reconsideration—Disability Cessation

• DI 33020.025 Reopenings